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` APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br />' ? Telephone (209) 466-6781 <br /> I i PERMIT EXPIRES-1'YEAR FROM DATE ISSUED WoIAku�_4 <br /> , ` (� <br /> (Complete in Triplicate) / Ate. <br /> N Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No::1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health`District. ,., <br /> j Job Address �� $� LG 4; City Sfivcl< 'oma Lot Size PM <br /> yY n /� S A /� <br /> I'f�Owner's Name �A '' 1. ��tr1' l(f/fe99 �� ess Phone <br /> l 4rContractor SGfG Address t t 5 A,"I License No. Phone <br /> 6 - <br /> TYPE OF WELL/PUMP:, N'EW.WELL:❑ V t} WELL—REPLACEMENT ❑' DESTRUCTION ❑ <br /> p PUMP INSTALLATION-❑ SYSTEM REPAIR ❑ OTHER ❑' <br /> Y. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP LINE <br /> FOUNDATION T AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM'AREAt CONSTRUCTION SPECIFICATIONS <br /> E <br /> psi ❑ Industrial 1i ❑Open Bottom ❑ Manteca .Dia. of Well Excavation Dia. of Well Casing <br /> hd ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> { •' F - <br /> i"1 Public j ❑ Other 1] Deltas a Depth of Grout Seal Type ofGrout <br /> ! _. <br /> I I Irrigation y _.-Approx. Depth l I Eastern -- Surface Seal Installed by _ <br /> Repair Work"Done ❑ Type of Pump H.P. State Work Done <br /> a, Well Destruction ❑ Well Diameter -`Sealing Material hop 501 1 <br /> I. Depth Filler Material (Below 501 <br /> d. TYPE OF SEPTIC`WORK: NEW INSTALLATION IJ REPAIR/ADDITION { I DESTRUCTION >(No septic system permitted if public sewer is <br /> _ available within 200 feet'.) j'n <br /> i• d Installation'will i,serve: Residence_ Commercial— Other <br /> N <br /> Number ofi living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 Water table depth( <br /> SEPTIC TANK ❑ T l <br /> • ype/Mfg �e Capacity No. Compartment`s <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> p Distance to nearest: WellFoundation Property.Line <br /> i LEACHING LINE ❑ No. & Length oflines <br /> ..x Total length/size <br /> FILTER BEDI' ❑ Distance to nearest:' Well Foundation Property Line <br /> SEEPAGE PITS [I Depth i Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of-the San Joaquin-L-ocal-Health-Distric-t.= ...-,w--.-,-,:....._-.,..,----- -- <br /> Home owner"or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> t The appli u c Aorall re red inspec' ns. Complete drawing on reverse side. <br /> Sign X Title: �� ��dt Date: <br /> I <br /> EPARTMENT USE ONLY <br /> -� --... <br /> Application Accepted b . <br /> PP � p Y - �� � Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Yy <br /> 6 'Additional Comments: <br /> ❑•Stk .466-,6781 ❑ Lodi 369-3621 ❑-Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE_ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ♦.-EH 13'-24.(REV.'�i x 5l / 3:5 4Da <br /> ^� Q: <br /> —_ Q <br /> EH 14-28 <br /> I <br />